BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA / STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B _ r , y w A Y� of COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. •CSI�•pN N� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ ❑ ❑ TANK RE N V CLOSED ONSITE 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: �v�r C. DATE INSTALLED(MO/DAY/YEAR) -J� 7 V D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL g C ❑ 1a REGULAR ❑ 3 DIESEL ❑ 2 PETROLEUM UNLEADED ❑ 6 AVIATION GAS ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE 2 LEADED ED ❑ 5 JET FUEL ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINERr 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100°/ METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING C.INTERIOR ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE PROTECTION A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 IN E S I IAL MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI,TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING3.WAS TANK FILLED WITH GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, lS TRUE AND CORRECT APPLICANTS NAME (PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# STATE 1.014 � TANK# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRE7 FORM A HAS BEEN FILED.' / FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0R00348-RS l•� I J r4!',I